DSM-5: The Ten Personality Disorders: Cluster B

Cluster B is called the dramatic, emotional, and erratic cluster. It includes Borderline Personality Disorder, Narcissistic Personality Disorder, Histrionic Personality Disorder, and Antisocial Personality Disorder. Disorders in this cluster share problems with impulse control and emotional regulation.

The Antisocial Personality Disorder* is characterized by a pervasive pattern of disregard for the rights of other people that often manifests as hostility and/or aggression. Deceit and manipulation are also central features. In many cases hostile-aggressive and deceitful behaviors may first appear during childhood. These children may hurt or torment animals or people. They may engage in hostile acts such as bullying or intimidating others. They may have a reckless disregard for property such as setting fires. They often engage in deceit, theft, and other serious violations of standard rules of conduct. When this is the case, Conduct Disorder (a juvenile form of Antisocial Personality Disorder) may be an appropriate diagnosis. Conduct Disorder is often considered the precursor to an Antisocial Personality Disorder.

In addition to reckless disregard for others, they often place themselves in dangerous or risky situations. They frequently act on impulsive urges without considering the consequences. This difficulty with impulse control results in loss of employment, accidents, legal difficulties, and incarceration. Persons with Antisocial Personality Disorder typically do not experience genuine remorse for the harm they cause others. However, they can become quite adept at feigning remorse when it is in their best interest to do so (such as when standing before a judge). They take little to no responsibility for their actions. In fact, they will often blame their victims for "causing" their wrong actions, or deserving of their fate. The aggressive features of this personality disorder make it stand out among other personality disorders as individuals with this disorder take a unique toll on society.

Persons with Histrionic Personality Disorder* are characterized by a pattern of excessive emotionality and attention seeking. Their lives are full of drama (so-called "drama queens"). They are uncomfortable in situations where they are not the center of attention. People with this disorder are often quite flirtatious or seductive, and like to dress in a manner that draws attention to them. They can be flamboyant and theatrical, exhibiting an exaggerated degree of emotional expression. Yet simultaneously, their emotional expression is vague, shallow, and lacking in detail. This gives them the appearance of being disingenuous and insincere. Moreover, the drama and exaggerated emotional expression often embarrasses friends and acquaintances as they may embrace even casual acquaintances with excessive ardor, or may sob uncontrollably over some minor sentimentality.

People with Histrionic Personality Disorder can appear flighty and fickle. Their behavioral style often gets in the way of truly intimate relationships, but it is also the case that they are uncomfortable being alone. They tend to feel depressed when they are not the center of attention. When they are in relationships, they often imagine relationships to be more intimate in nature than they actually are. People with Histrionic Personality Disorder tend to be suggestible; that is, they are easily influenced by other people's suggestions and opinions. A literary character that exemplifies the Histrionic Personality Disorder is the character of Blanche DuBois in Tennessee William's classic play, "Streetcar Named Desire."

People with Narcissistic Personality Disorder* have significant problems with their sense of self-worth stemming from a powerful sense of entitlement. This leads them to believe they deserve special treatment, and to assume they have special powers, are uniquely talented, or that they are especially brilliant or attractive. Their sense of entitlement can lead them to act in ways that fundamentally disregard and disrespect the worth of those around them.

People with Narcissistic Personality Disorder are preoccupied with fantasies of unlimited success and power, so much so that they might end up getting lost in their daydreams while they fantasize about their superior intelligence or stunning beauty. These people can get so caught up in their fantasies that they don't put any effort into their daily life and don't direct their energies toward accomplishing their goals. They may believe that they are special and deserve special treatment, and may display an attitude that is arrogant and haughty. This can create a lot of conflict with other people who feel exploited and who dislike being treated in a condescending fashion. People with Narcissistic Personality Disorder often feel devastated when they realize that they have normal, average human limitations; that they are not as special as they think, or that others don't admire them as much as they would like. These realizations are often accompanied by feelings of intense anger or shame that they sometimes take out on other people. Their need to be powerful, and admired, coupled with a lack of empathy for others, makes for conflictual relationships that are often superficial and devoid of real intimacy and caring.

Status is very important to people with Narcissistic Personality Disorder. Associating with famous and special people provides them a sense of importance. These individuals can quickly shift from over-idealizing others to devaluing them. However, the same is true of their self-judgments. They tend to vacillate between feeling like they have unlimited abilities, and then feeling deflated, worthless, and devastated when they encounter their normal, average human limitations. Despite their bravado, people with Narcissistic Personality Disorder require a lot of admiration from other people in order to bolster their own fragile self-esteem. They can be quite manipulative in extracting the necessary attention from those people around them.

Borderline Personality Disorder* is one of the most widely studied personality disorders. People with Borderline Personality Disorder tend to experience intense and unstable emotions and moods that can shift fairly quickly. They generally have a hard time calming down once they have become upset. As a result, they frequently have angry outbursts and engage in impulsive behaviors such as substance abuse, risky sexual liaisons, self-injury, overspending, or binge eating. These behaviors often function to sooth them in the short-term, but harm them in the longer term.

People with Borderline Personality Disorder tend to see the world in polarized, over-simplified, all-or-nothing terms. They apply their harsh either/or judgments to others and to themselves and their perceptions of themselves and others may quickly vacillate back and forth between "all good" and "all bad." This tendency leads to an unstable sense of self, so that persons with this disorder tend to have a hard time being consistent. They can frequently change careers, relationships, life goals, or residences. Quite often these radical changes occur without any warning or advance preparation.

People with Borderline Personality Disorder tend to view the world in terms of black-and-white, or all-or-nothing thinking. Their tendency to see the world in black-or-white (polarized) terms makes it easy for them to misinterpret the actions and motivations of others. These polarized thoughts about their relationships with others lead them to experience intense emotional reactions, which in turn interacts with their difficulties in regulating these intense emotions. The result is that they will characteristically experience great distress which they cannot easily control and may subsequently engage in self-destructive behaviors as they do their best to cope. The intensity of their emotions, coupled with their difficulty regulating these emotions, leads them to act impulsively.

To illustrate the way black-and-white thinking, emotional dys-regulation, and poor impulse regulation all merge and culminate to create interpersonal conflict and distress, let's use an example. Suppose the partner of a woman with Borderline Personality Disorder fails to remember their anniversary. Black-and-white thinking causes her to conclude, "He doesn't love me anymore" and all-or-nothing thinking leads her to (falsely) conclude, "If he does not love me, then he must hate me." Such thoughts would easily lead to some pretty intense emotions, such as feeling rejected, abandoned, sad, and angry. She has a hard time tolerating and dealing with these intense feelings and consequently becomes highly upset and overwhelmed. The intensity of her negative feelings seems unbearable. Next she has a powerful impulse to "do something" just so that these feelings will go away. She might angrily accuse her partner of having an affair and she might plead with her partner not to leave her.

Meanwhile her partner is baffled by this extreme reaction, particularly since he is not having an affair, and he readily recalls all his other recent loving gestures. Her partner might also become angry at these wild accusations of infidelity and so the conflict escalates and things get more intense. Alone after the fight, the woman feels overwhelming self-loathing or numbness and goes on to intentionally injure herself (by cutting or burning herself) as a way to cope with her numbness. When her partner learns about this self-harm behavior he can't understand it and concludes he is being manipulated. He expresses his strong concern for her well-being but also his anger. In turn, she feels misunderstood. Clearly, the Borderline Personality Disorder with its combination of distorted thought patterns, intense and under-regulated emotions, and poor impulse control is practically designed to wreak havoc on any interpersonal relationship.

*It is important to remember that everyone can exhibit some of these personality traits from time to time. To meet the diagnostic requirement of a personality disorder, these traits must be inflexible; i.e., they can be regularly observed without regard to time, place, or circumstance. Furthermore, these traits must cause functional impairment and/or subjective distress. Functional impairment means these traits interfere with a person's ability to functional well in society. The symptoms cause problems in interpersonal relationships; or at work, school, or home. Subjective distress means the person with a personality disorder may experience their symptoms as unwanted, harmful, painful, embarrassing, or otherwise cause them distress. The above list only briefly summarizes these individual Cluster B personality disorders. Richer, more detailed descriptions of these disorders are found in the section describing the four core features of personality disorders.